Peritoneal Dialysis International, Vol. 30, pp. 424429 0896-8608/10 $3.00 + .

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doi:10.3747/pdi.2010.00087 Copyright 2010 International Society for Peritoneal Dialysis

CLINICAL PRACTICE GUIDELINES FOR PERITONEAL ACCESS

Ana Figueiredo,1 Bak-Leong Goh,2 Sarah Jenkins,3 David W. Johnson,4 Robert Mactier,5
Santhanam Ramalakshmi,6 Badri Shrestha,3 Dirk Struijk,7 and Martin Wilkie3

Faculdade de Enfermagem, Nutrio e Fisioterapia,1 Pontifcia Universidade Catlica do Rio Grande do Sul,
Brazil; Department of Nephrology,2 Serdang Hospital, Jalan Puchong, Kajang, Selangor, Malaysia;
Sheffield Kidney Institute,3 Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United
Kingdom; Nephrology,4 Princess Alexandra Hospital, Woolloongabba, Brisbane, Queensland, Australia;
Renal Services,5 Glasgow Royal Infirmary, Glasgow, Scotland, United Kingdom; Nephrology,6
Sri Ramachandra University, Chennai, India; Dialysis Unit,7 Dianet Dialysis Centers and

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Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

T his current version provides a summary of recommen-

dations for best practice in creating peritoneal access
for patients on peritoneal dialysis (PD). A more detailed
dations as strong (Grade 1) or weak (Grade 2) based
upon the balance between the benefits and risks, bur-
den, and cost. The quality or level of evidence is desig-
review of peritoneal access is available in the report from nated as high (Grade A), moderate (Grade B), low
the Renal Association Working Party on Peritoneal Access (Grade C), or very low (Grade D) depending on factors
(final version April 2008) available at www.renal.org. such as study design, directness of evidence, and con-
These guidelines are evidence based where such evi- sistency of results. Grades of recommendation and qual-
dence exists. The published literature was reviewed at ity of evidence may range from 1A to 2D.
www.ncbi.nlm.nih.gov/pubmed using the search term The GRADE system was developed by an international
peritoneal dialysis catheter, identifying 2320 refer- group of guideline developers and methodologists to
ences. Adding the term trial reduced this number to maximize the usefulness of clinical practice guidelines
216. These were individually reviewed to identify pos- in the management of typical patients (17). Most guide-
sible randomized controlled trials, meta-analyses, line organizations recognize the need for a standard
guidelines, and reviews that would be considered in the grading scheme and the GRADE system has been adopted
preparation of the document. The document has been by many leading organizations, including NICE, SIGN,
reviewed by all authors and has been placed for consul- KDIGO, ERBP, and KDOQI, as well as UpToDate (8,9).
tation on the Renal Association Web site and discussed
at the Clinical Guidelines Committee. It has also been FULL CLINICAL PRACTICE GUIDELINES FOR
reviewed by a consumer research panel run by Jane Ash PERITONEAL DIALYSIS ACCESS
(Special Projects Administrator, North and East Yorkshire
and Northern Lincolnshire Comprehensive Local Re- GUIDELINE 1: THE ACCESS TEAM
search Network) and by renal patients in Sheffield,
United Kingdom. Guideline 1.1: The Access Team (1C): We recommend
The evidence for these recommendations has been that each center should have a dedicated team in-
assessed using the modified GRADE system. The modi-
fied GRADE system defines both the strength of the rec- Perit Dial Int 2010; 30:424429 www.PDIConnect.com
ommendations of the guideline authors and the level of doi:10.3747/pdi.2010.00087
evidence upon which each of the recommendations is
based. This grading system classifies expert recommen- Correspondence to: M. Wilkie, Sheffield Kidney Institute,
Renal Sorby E Floor, Sheffield Teaching Hospitals NHS Foun-
Posted at www.renal.org/guidelines. Please check for updates. dation Trust, Herries Road, Sheffield, S5 7AU United Kingdom.
Please send feedback for the next edition to martin.wilkie@ martin.wilkie@sth.nhs.uk
sth.nhs.uk Received 3 March 2010; accepted 3 May 2010.
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PDI JULY 2010 VOL. 30, NO. 4
volved in the implantation and care of peritoneal
catheters.
Rationale: The access team should comprise nurses,
nephrologists, and surgeons who have experience in
peritoneal dialysis (PD). Each member of the team should
understand the importance to the patient of successful
access placement and the need for attention to detail in
the reduction of complications (10).
GUIDELINE 2: TIMING AND COORDINATION OF REFERRAL AND
SURGERY
Guideline 2.1: Timing and Coordination of Referral and
Surgery (2B): We suggest that, whenever possible, cath-
eter insertion should be performed at least 2 weeks be-
fore starting PD. Small dialysate volumes in the supine
position can be used if dialysis is required earlier.
Rationale: There are two main patient groups requir-
ing PD access:
1. Patients with progressive renal failure predicted to
need dialysis: For these patients, access should be
coordinated from the chronic kidney disease low
clearance clinic. The objective is placement of ac-
cess sufficiently early to enable the patient to train
for PD in a timely fashion while residual renal func-
tion is sufficient, and to avoid the need for tempo-
rary vascular access for hemodialysis if there are
problems with catheter function. It is not recom-
mended that patients commencing PD have an arte-
riovenous fistula formed unless there is a plan to
transfer to hemodialysis within a few months or some
clinical doubt regarding the viability of PD in a given
patient beyond a few months.
2. Patients with stage 5 chronic kidney disease pre-
senting as uremic emergencies [late referrals; 23%
of new patients in the UK (11)]: For these patients
there should be a pathway that allows the choice of
PD as a modality. This requires adequate patient edu-
cation to be available to permit choice. The advan-
tage of placing PD access in patients who have not
had the opportunity to be prepared for renal re-
placement therapy is that the requirement for pro-
longed use of central venous access can be reduced.
This has to be balanced against the potential for
complications associated with the early use of PD
catheters (12).
It seems appropriate to adopt the European Best Prac-
tice standard for the timing of PD catheter insertion:
Whenever possible, the catheter insertion should be
performed at least 2 weeks before starting peritoneal
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PERITONEAL ACCESS GUIDELINES
dialysis. Small dialysate volumes in the supine position
can be used if dialysis is required during this period
(13).
GUIDELINE 3: IMPLANTATION PROTOCOL
Guideline 3.1: Implantation Protocol (1A): We recom-
mend that renal units should have clear protocols for
perioperative catheter care, including the use of antibi-
otic prophylaxis.
Rationale: The following points should be included in
the perioperative catheter care protocol:
Preoperative: checking for hernias and screening for
methicillin-resistant Staphylococcus aureus (MRSA)
and nasal carriage of S. aureus; identifying a cath-
eter of a suitable length; marking the exit site with
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the patient sitting or standing.
Pre-implantation: preparing the bowel with laxa-
tives; ensuring bladder emptying; administering
prophylactic antibiotics; preparing surgical site ac-
cording to NICE guidance (14).
Post-procedure: flushing catheter and capping off
using suitable dialysate; covering exit site with a
suitable nonocclusive dressing and, if possible, not
disturbing for 5 10 days; immobilizing the cath-
eter; discharging patient home with supply of
aperients and advice on recognizing potential com-
plications. Once the catheter is placed and until
healing is completed, the dressing changes should
be done by a dialysis nurse using sterile technique.
Administration of prophylactic antibiotics is recom-
mended to reduce the risk of catheter-site infection,
peritonitis, and wound sepsis and there is randomized
controlled trial (RCT) evidence for the use of vancomy-
cin (15). The Cochrane Collaboration found four trials of
intravenous antibiotics and found the evidence to be
strong in preventing catheter insertion-associated early
peritonitis but not tunnel or exit-site infection (16). This
evidence is also reviewed in the ISPD peritonitis guide-
lines (17). The choice of antibiotic should be based upon
local guidelines, with consideration given to efficacy,
risks of selection of resistant organisms, and develop-
ment of Clostridium difficile colitis.
GUIDELINES 4: THE IMPLANTATION TECHNIQUE
Guideline 4.1: The Implantation Technique (1B): We
recommend that local expertise at individual centers
should govern the choice of method of PD catheter
insertion.
425
FIGUEIREDO et al.
Guideline 4.2: The Implantation Technique (1B): We
recommend that each PD unit should have the ability to
manipulate or reimplant PD catheters when necessary.
Guideline 4.3: The Implantation Technique (1A): We
recommend that urgent removal of PD catheters should
be available where necessary.
Rationale: Catheter removal is indicated either acutely
in the case of PD peritonitis or as a planned procedure,
for example, following renal transplantation or switch
to hemodialysis. For the planned procedure, catheter
removal can be performed as a day case. Under certain
circumstances, simultaneous removal and replacement
has been described for certain indications, for example,
localized exit-site infection or during remission follow-
ing relapsing peritonitis (18). This should not be done
for tunnel infection or active peritonitis.
Guideline 4.4: The Implantation Technique (1A): We
recommend that timely surgical support should be avail-
able for the review of PD patients.
Rationale: There is no RCT evidence to support one
method of insertion over another; however, the method
needs be determined by patient characteristics. For more
complicated patients, including those with previous sig-
nificant abdominal surgery, a technique that involves
direct vision is necessary, such as laparoscopic or open
insertion (19).
Peritoneal access surgery is generally considered part
of the overall requirement for dialysis access and should
include facilities for both catheter insertion and cath-
eter removal. Data from the UK Renal Registry indicate
that the incident renal replacement population was
113 per million of the population in 2004, with 20%
starting on PD (11). About two thirds of catheter inser-
tions in the UK are performed using the open surgical
technique and the majority of the others are done using
the medical percutaneous technique.
GUIDELINE 5: FACILITIES FOR PD CATHETER INSERTION
Guideline 5.1: Facilities for PD Catheter Insertion (1A):
We recommend that a dedicated area should be used for
catheter insertion, with appropriate staffing, suction,
oxygen, and patient monitoring facilities.
Rationale: The anesthetic requirement depends on the
technique selected, which is influenced by the charac-
teristics of the patient. Typically, for percutaneous or
peritoneoscopic routes, sedation may be required (20).
Conscious sedation needs to be managed according to
local clinical governance procedures.
Guideline 5.2: Facilities for PD Catheter Insertion (2C):
We suggest that no particular catheter type has been
proven to be better than another.
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Rationale: The Cochrane Review did not find any ad-
vantage for straight versus coiled catheters, single or
double cuff, median or lateral incision (21). However, a
RCT reported improved primary catheter function (22)
and improved PD technique survival for straight versus
coiled catheters (23). A further RCT reported that coiled
catheters might have higher migration rates than
straight catheters (24). These data relate to relatively
small studies and we would not advocate at this stage
that centers with good outcomes change their choice of
catheter type until more information is available. Al-
though subcutaneous burying of the catheter until use
(Moncrief method) was not associated with a reduction
in infectious complications (25), its use may have ad-
vantages for the relationship between the timing of cath-
eter insertion and the start of training.
Guideline 5.3: Facilities for PD Catheter Insertion (2C):
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We suggest that a catheter of a suitable length should
be used.
Rationale: It is good practice to make an assessment
of the required length of the peritoneal catheter since a
catheter of inappropriate length can lead to pain or
impaired function (26,27). We draw attention to the pub-
lications by John Crabtree describing a method to de-
termine the appropriate length for the PD catheter (27).
Guideline 5.4: Facilities for PD Catheter Insertion (2C):
We suggest that PD catheters should be inserted as day
case procedures in selected cases as long as this does
not compromise the quality of care.
Rationale: The use of day case facilities has consider-
able advantages for the patient and resource utilization
(28). However, local practices vary with respect to patient
preparation and post-insertion care, and these should
take priority over the length of in-patient stay (29).
GUIDELINE 6: TRAINING FOR PD CATHETER INSERTION
Guideline 6.1: Training for PD Catheter Insertion (1C):
We recommend that PD catheter insertion training
should be available to all trainees with an interest.
Rationale: Renal Association training committees
should advise the inclusion of PD catheter insertion as
an optional component of the curriculum for trainees,
although this will not be taken up by all trainees (30). A
procedure-based competency for PD catheter insertion
should be included in renal medicine specialty training
curricula.
Guideline 6.2: Training for PD Catheter Insertion (1A):
We recommend that PD catheter insertion should not be
delegated to inexperienced unsupervised operators.
Rationale: Successful peritoneal access is crucial and
should be performed by an operator (surgeon, special-
PDI JULY 2010 VOL. 30, NO. 4
ist nurse, or physician) with training and expertise in
creating peritoneal access (10).
GUIDELINE 7: AUDIT OF PD CATHETER INSERTION
Guideline 7.1: Audit of PD Catheter Insertion (1B): We
recommend that there should be regular audit at not less
than 12-month intervals of the outcome of catheter in-
sertion as part of multidisciplinary meetings of the PD
team and the access operators.
Rationale: There is RCT evidence to demonstrate that
audit can improve practice (31). The primary marker of
successful outcome is primary catheter patency. Al-
though we do not have a specific audit standard in this
area, it has been recommended that > 80% of catheters
should be patent at 1 year (censoring for death and elec-
tive modality change) (10). The following are audit stan-
dards for catheter-related complications:
Bowel perforation: < 1%
Significant hemorrhage: < 1%
Exit-site infection within 2 weeks of catheter inser-
tion: < 5%
Peritonitis within 2 weeks of catheter insertion: < 5%
Functional catheter problem requiring manipulation
or replacement or leading to technique failure: < 20%
At least every 12 months, a combined meeting be-
tween surgeons (or other healthcare providers insert-
ing PD catheters) and the nephrology team should be
held to review PD catheter data.
Data to be collected and used in the audit should
include
Perioperative complications, including bowel perfo-
ration and/or significant hemorrhage (requiring
transfusion or surgical intervention)
Early infections: peritonitis and exit-site infections
within 2 weeks of catheter insertion
Dialysate fluid leak
Catheter dysfunction at the time of first use that re-
quires catheter manipulation or replacement or re-
sults in technique failure
SUMMARY
Clinical Practice Guidelines for Peritoneal Access (Modified
GRADE of Recommendation and Evidence)
Guideline 1: Access team
Guideline 1.1 We recommend that each center should have
a dedicated team involved in the implanta-
tion and care of peritoneal catheters (1C).
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PERITONEAL ACCESS GUIDELINES
Guideline 2: Timing
Guideline 2.1 We suggest that, whenever possible, cath-
eter insertion should be performed at least
2 weeks before starting PD. Small dialysate
volumes in the supine position can be used
if dialysis is required earlier (2B).
Guideline 3: Implantation protocol
Guideline 3.1 We recommend that renal units should have
clear protocols for perioperative catheter
care, including the use of antibiotic prophy-
laxis (1A).
Guideline 4: Implantation technique
Guideline 4.1 We recommend that local expertise at indi-
vidual centers should govern the choice of
method of PD catheter insertion (1B).
Guideline 4.2 We recommend that each PD unit should have
the ability to manipulate or reimplant PD
catheters when necessary (1B).
Guideline 4.3 We recommend that urgent removal of PD
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catheters should be available where neces-
sary (1A).
Guideline 4.4 We recommend that timely surgical support
should be available for the review of PD pa-
tients (1A).
Guideline 5: Facilities
Guideline 5.1 We recommend that a dedicated area should
be used for catheter insertion with appro-
priate staffing, suction, oxygen, and patient
monitoring facilities (1A).
Guideline 5.2 We suggest that no particular catheter type
is proven to be better than another (2C).
Guideline 5.3 We suggest that a catheter of a suitable size
should be used (2C).
Guideline 5.4 We suggest that PD catheters should be in-
serted as day case procedures as long as this
does not compromise the quality of care (2C).
Guideline 6: Training
Guideline 6.1 We recommend that PD catheter insertion
training should be available to all trainees
with an interest (1C).
Guideline 6.2 We recommend that PD catheter insertion
should not be delegated to inexperienced
unsupervised operators (1A).
Guideline 7: Audit
Guideline 7.1 We recommend that there should be regular
audit at not less than 12-month intervals of
the outcome of catheter insertion as part of
multidisciplinary meetings of the PD team
and the access operators (1B).
PD = peritoneal dialysis.
Audit Measures
1. Catheter patency: more than 80% of catheters should be
patent at 1 year (censoring for death and elective modality
change)
427
FIGUEIREDO et al.
2. Complications following peritoneal dialysis catheter
insertion:
Bowel perforation: < 1%
Significant hemorrhage: < 1%
Exit-site infection within 2 weeks of catheter inser-
tion: < 5%
Peritonitis within 2 weeks of catheter insertion: < 5%
Functional catheter problem requiring manipulation or
replacement or leading to technique failure: < 20%
DISCLOSURES
Ana Figueiredo has received speakers honoraria from
Baxter and travel sponsorship from Baxter and Fresen-
ius. Bak-Leong Goh has received speakers honoraria
from Baxter. Sarah Jenkins has received speakers hono-
raria and a travel grant from Baxter. David Johnson has
received speakers honoraria from Baxter and Fresenius
and has participated in clinical trials with Baxter, Fre-
senius, and Gambro. He has been a consultant to Baxter
and Gambro and has received travel sponsorships from
Baxter and Fresenius. He is also the recipient of a Baxter
Extramural Research Grant. Robert Mactier has received
travel sponsorship from Amgen, Leo, and Roche and has
participated in multicenter clinical trials sponsored by
Amgen, Baxter, and Roche. He has participated in Advi-
sory Board meetings for Amgen and Baxter. Dirk Struijk
has received lecturing honoraria from Baxter and has
participated in clinical trials with Baxter. Martin Wilkie
has received speakers honoraria from Gambro, Baxter,
and Fresenius and has participated in clinical trials with
Baxter and Fresenius.
ACKNOWLEDGMENTS
These guidelines have drawn extensively on the UK Renal As-
sociation PD Access Working Party (2008). Members were
Jonathan Barratt, Robert H. Diament, Stephen Holt, Helen
Hurst, C.G. Winearls, as well as Badri Shrestha and Martin
Wilkie.
REFERENCES
1. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp
S, et al.; GRADE Working Group. Grading quality of evi-
dence and strength of recommendations. BMJ 2004; 328:
1490.
2. Guyatt G, Gutterman D, Baumann MH, Addrizzo-Harris D,
Hylek EM, Phillips B, et al. Grading strength of recommen-
dations and quality of evidence in clinical guidelines: re-
port from an American College of Chest Physicians task
force. Chest 2006; 129:17481.
3. Guyatt GH, Vist GE, Falck-Ytter Y, Kunz R, Magrini N,
This single copy is for your personal, non-commercial use only.
428 For permission to reprint multiple copies or to order presentation-ready
copies for distribution, contact Multimed Inc. at
marketing@multi-med.com Copyright 2010 Multimed Inc.
JULY 2010 VOL. 30, NO. 4 PDI
Schnemann H. An emerging consensus on grading rec-
ommendations? ACP J Club 2006; 144:A89.
4. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y,
Alonso-Coello P, et al. GRADE: An emerging consensus on
rating quality of evidence and strength of recommenda-
tions. BMJ 2008; 336:9246.
5. Guyatt GH, Oxman AD, Kunz R, Jaeschke R, Helfond M,
Liberati A, et al. GRADE: Incorporating considerations of
resources use into grading recommendations. BMJ 2008;
336:11703.
6. Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE,
Liberati A, et al. GRADE: Going from evidence to recom-
mendations. BMJ 2008; 336:104951.
7. Jaeschke R, Guyatt GH, Dellinger P, Schnemann H, Levy
MM, Kunz R, et al. Use of GRADE grid to reach decisions on
clinical practice guidelines when consensus is elusive. BMJ
2008; 337:32730.
8. Uhlig K, MacLeod A, Craig J, Lau J, Levey AS, Levin A, et al.
Grading evidence and recommendations for clinical prac-
Downloaded from http://www.pdiconnect.com/ by guest on June 3, 2014
tice guidelines in nephrology. A position statement from
Kidney Disease: Improving Global Outcomes (KDIGO). Kid-
ney Int 2006; 70:205865.
9. Kidney Disease: Improving Global Outcomes. KDIGO clini-
cal practice guidelines for the prevention, diagnosis,
evaluation and treatment of hepatitis C in chronic kidney
disease. Kidney Int Suppl 2008; (109):S199.
10. Flanigan M, Gokal R. Peritoneal catheters and exit-site
practices toward optimum peritoneal access: a review of
current developments. Perit Dial Int 2005; 25:1329.
11. The Renal Association. Chapter 13: New adult patients
starting renal replacement therapy in the UK in 2004. In:
UK Renal Registry. The Eighth Annual Report 2005.
Bristol, UK: The Renal Association; 2005: 1538.
12. Povlsen JV, Ivarsen P. How to start the late referred ESRD
patient urgently on chronic APD. Nephrol Dial Transplant
2006; 21(Suppl 2):ii569.
13. Dombros N, Dratwa M, Feriani M, Gokal R, Heimburger O,
Krediet R, et al. European best practice guidelines for peri-
toneal dialysis. 3 Peritoneal access. Nephrol Dial Transplant
2005; 20(Suppl 9):ix812.
14. Leaper D, Burman-Roy S, Palanca A, Cullen K, Worster D,
Gautam-Aitken E, et al. Prevention and treatment of sur-
gical site infection: summary of NICE guidance. BMJ 2008;
337:a1924.
15. Gadallah MF, Ramdeen G, Mignone J, Patel D, Mitchell L,
Tatro S. Role of preoperative antibiotic prophylaxis in pre-
venting postoperative peritonitis in newly placed perito-
neal dialysis catheters. Am J Kidney Dis 2000; 36:101419.
16. Strippoli GF, Tong A, Johnson D, Schena FP, Craig JC.
Antimicrobial agents to prevent peritonitis in peritoneal
dialysis: a systematic review of randomized controlled tri-
als. Am J Kidney Dis 2004; 44:591603.
17. Piraino B, Bailie GR, Bernardini J, Boeschoten E, Gupta
A, Holmes C, et al. Peritoneal dialysis-related infections
recommendations: 2005 update. Perit Dial Int 2005; 25:
10731.
PDI JULY 2010 VOL. 30, NO. 4 PERITONEAL ACCESS GUIDELINES

18. Mitra A, Teitelbaum I. Is it safe to simultaneously remove S12731.

and replace peritoneal dialysis catheters? Review of the
literature and suggested guidelines. Adv Perit Dial 2003;
19:2559.
19. Crabtree JH. Fluoroscopic placement of peritoneal dialy-
sis catheters: a harvest of the low hanging fruits. Perit
Dial Int 2008; 28:1347.
20. Zappacosta AR, Perras ST, Closkey GM. Seldinger technique
for Tenckhoff catheter placement. ASAIO Trans 1991; 37:
1315.
21. Strippoli GF, Tong A, Johnson D, Schena FP, Craig JC. Cath-
eter type, placement and insertion techniques for prevent-
ing peritonitis in peritoneal dialysis patients. Cochrane
Database Syst Rev 2004; 4:CD004680.
22. Stegmayr BG, Wikdahl AM, Bergstrom M, Nilsson C,
Engman U, Arnerlov C, et al. A randomized clinical trial
comparing the function of straight and coiled Tenckhoff
catheters for peritoneal dialysis. Perit Dial Int 2005; 25:
858.
25. Danielsson A, Blohme L, Tranaeus A, Hylander B. A pro-
spective randomized study of the effect of a subcutane-
ously buried peritoneal dialysis catheter technique
versus standard technique on the incidence of peritonitis
and exit-site infection. Perit Dial Int 2002; 22:21119.
26. Crabtree JH, Burchette RJ, Siddiqi NA. Optimal peritoneal
dialysis catheter type and exit site location: an anthro-
pometric analysis. ASAIO J 2005; 51:7437.
27. Crabtree JH. Selected best demonstrated practices in peri-
toneal dialysis access. Kidney Int Suppl 2006; (103):S2737.
28. Kelly J, McNamara K, May S. Peritoneoscopic peritoneal
dialysis catheter insertion. Nephrology (Carlton) 2003;
8:31517.
29. Henderson S, Brown E, Levy J. Safety and efficacy of per-
cutaneous insertion of peritoneal dialysis catheters under
sedation and local anaesthetic. Nephrol Dial Transplant
2009; 24:3499504. Epub ahead of print 25 Jun 2009:
doi:10.1093/ndt/gfp312.

Downloaded from http://www.pdiconnect.com/ by guest on June 3, 2014

23. Johnson DW, Wong J, Wiggins KJ, Kirwan R, Griffin A,
Preston J, et al. A randomized controlled trial of coiled
versus straight swan-neck Tenckhoff catheters in perito-
neal dialysis patients. Am J Kidney Dis 2006; 48:81221.
24. Lo WK, Lui SL, Li FK, Choy BY, Lam MF, Tse KC, et al. A pro-
spective randomized study on three different peritoneal
dialysis catheters. Perit Dial Int 2003; 23(Suppl 2):
30. Berns JS, ONeill WC. Performance of procedures by
nephrologists and nephrology fellows at U.S. nephrology
training programs. Clin J Am Soc Nephrol 2008; 3:9417.
31. Jamtvedt G, Young JM, Kristoffersen DT, OBrien MA,
Oxman AD. Audit and feedback: effects on professional
practice and health care outcomes. Cochrane Database Syst
Rev 2006; 2:CD000259.

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